13 District General Hospitals in Wales are working collaboratively with the 1000 Lives Improvement service at Public Health Wales to improve the care they provide to patients undergoing emergency laparotomy surgery (emergency bowel surgery).

This work is part of an all wales quality improvement programme called Emergency Laparotomy Cymru (ELC) launched in July 2018.

ELC focusses on a patient’s care, from the time of the individual presenting to hospital, throughout their perioperative journey and during recovery.

Hospitals are using a 6-step evidence-based care bundle approach to deliver improvements.

A data collection system known as NELA (the National Emergency Laparotomy Audit) is used, to better understand individual standards of care and use data to make improvements.

Three clinical leads have been appointed to progress the work across local regions. Over the next few months, they will be sharing their thoughts over why this programme is so important and will discuss how it’s developing. Each lead will be working closely with other members of a multi-disciplinary team from each hospital within their region. This will consist of staff across emergency departments, radiology, theatre, critical care and surgical wards.

In this first blog, we speak with DrBabu Muthuswamy, South East clinical lead. Babu is a Consultant in Anaesthesia and Intensive Care and Clinical Director for Critical Care at Aneurin Bevan University Health Board.

In your opinion, why is ELC so important?

In Wales, a number of hospitals have good clinical pathways to improve the care and outcomes of patients undergoing emergency laparotomy but there is still variation in processes and outcomes for patients having this high-risk surgery.

ELC has been launched to support NHS Wales in improving patient outcomes across Wales. We are striving to ensure that outcomes and satisfaction levels, for patients and their wider family members, rank as some of the best in the UK.

What made you want to get involved?

I have been part of the NELA audit since its roll out 2014 and have been the lead for the Royal Gwent Hospital throughout this period. There have been numerous challenges along the way in relation to improving the processes of care to emergency laparotomy patients. Being part of a national project like this helps to raise the profile of this work and to highlight the high-risk nature of this surgical procedure. It also helps to focus the minds of multi-disciplinary teams in each hospital to work towards one aim which is improving care and patient outcomes.

What do you hope it will achieve?

Through ELC I am hopeful that we can improve patient outcomes from:

Having evidence-based practice guidelines as elements of the ELC bundle;

Providing a support network for the NELA leads in each of the hospitals involved;

Improving the scope of research to refine current practice; and

Disseminating successful clinical pathways that have been adopted in other hospitals (across the UK).

ELC is following a UK model that has been tried and tested, having achieved successful results.

It’s been a busy few months since I joined Public Health Wales in the summer – although I’m not complaining! When I first arrived, I was also part time in my role as Executive Director of Continuous Improvement in the Aneurin Bevan University Health Board and so was effectively wearing two hats. Now, a few months in to the full time role, I continue to be astounded by the volume of work going on and commitment of the team within 1000 Lives Improvement.

The last several months really has been a journey of discovery and information gathering and I have met many stakeholder groups in order to gain an in depth understanding of an organisation that’s already in its tenth year – I’m hearing some really great things.

In going through that journey, however, there is a clear recognition that the 1000 Lives team need to evolve the way that they support Quality Improvement within Wales. I think 2019 is going to be an exciting time for 1000 Lives Improvement. We are looking at what we do and how we do it to enable us to support NHS Wales and Social Care to improve services and achieve the vision set out in Welsh Government’s A Healthier Wales: our Plan for Health and Social Care (2018).

Responding to The Parliamentary Review of Health and Social Care in Wales (2018), the plan sets out a long-term future vision of a ‘whole system approach to health and social care’, which is focussed on health and wellbeing, and on preventing illness. It calls for transformation to an integrated system, with new models of seamless local health and social care and we’re developing plans around how we can support you to deliver this transformation. The 1000 Lives team is well placed to support this.

To inform our thinking, we’d like to hear from all staff and services about your service improvement experience and what you’d like help with moving forwards. Please share your thoughts with us via our online survey.

We’ll be feeding back in the New Year about what we learn and how we can support you moving forwards – keep an eye on our website, newsletter and social media for the most recent updates.

As I walked to a meeting in the Children’s Hospital for Wales recently, I found myself reflecting on how much has happened since I came into post in January, when prior to my current role, I was based at that very hospital.

My nursing career commenced in 1984 when I started my RGN training in Bangor, North Wales, close to my home town on Anglesey. Upon qualifying, I started as a Staff Nurse on the paediatric unit before obtaining my RSCN in Great Ormond Street in 1989. I then moved to Cardiff where my career has progressed to the present day. I feel I have been fortunate to have insight into paediatric nursing in both rural and urban settings, in tertiary and district general hospitals. This insight has proved invaluable to me in connecting with new colleagues from hospitals across Wales and to understand some of the pressures they experience and the challenges they seek to overcome.

Not all the changes I have seen during my career have been positive, but the introduction of the Nurse Staffing Levels (Wales) Act, 2016 I believe will be one of the most important changes I have witnessed. I consider it to be a positive step for health boards, nursing staff and most importantly, for our children, young people and their families.

The All Wales Nurse Staffing Programme supports NHS Wales in meeting the requirements of the Nurse Staffing Levels (Wales) Act, which places a legal duty upon health boards and trusts to ensure that they are providing sufficient nurses to allow nurses time to care for patients sensitively.

The role of the paediatric work stream is to devise an evidence based approach to determine appropriate staffing levels within identified paediatric inpatient wards. The approach must be evidenced in the Welsh context and follow a common model of triangulation, which centres on three critical sources of knowledge: patient acuity, quality indicators and professional judgement. To date, 18 inpatient paediatric wards over the five health boards have been involved in capturing the acuity data for the audits on a twice daily basis.

In June this year, we hosted a successful paediatric event where paediatric nurses came together from across Wales to share their knowledge and expertise in reviewing and revising the new draft paediatric Welsh levels of care in preparation for testing on the wards.

My enthusiasm for this project has intensified during this time, due to fantastic reception I have received from colleagues across the whole of Wales and the sense that something very significant can be achieved through collaborative working, forming partnerships and support systems that could potentially transcend the aims of the current project.

During my work placement with the 1000 Lives Improvement team, I have enjoyed a variety of sessions in different areas in the department and have learned about the ways that the team improve outcomes for NHS Wales service users.

My learning around IQT…

A particular highlight for me was discussing IQT training with Keely McCarthy (Improvement Manager) and being able to complete the Bronze level IQT later on that day. I learned about the different levels of IQT training that can be carried out by NHS staff. I felt that the way the levels are taught by enhancing lateral thinking, would greatly improve confidence and teamwork. Using evidence-based practice by collecting data before, during and after small changes were made to departments, helps massively with implementing a change on a larger scale, if successful, and making adjustments if necessary. The most important thing I learned was that any member of NHS staff could take part and implement changes to make improvements to patients and staff-wellbeing. It is great that all staff members can be involved in improving quality, rather than this solely happening at a senior level.

The All Wales Nurse Staffing Programme…

I thoroughly enjoyed my time at the Prince of Wales hospital, where I was able to watch Dawn Parry (Paediatric Project Lead of the All Wales Nurse Staffing Programme) talk to paediatric nurses, doctors and healthcare assistants about patient acuity and the All Wales Nurse Staffing Programme. I was unaware of patient acuity levels (grading patients 1 to 5 based on the level of care needed and the time it takes to provide this care) before spending the morning with Dawn. The importance of correctly grading patients to ensure safe levels of Nursing staff on wards was emphasised in the presentation, and I found the interactive nature of these sessions really interesting and informative. I also spent the day at Singleton Hospital watching Joanna Doyle (All Wales Nurse Staffing Programme Manager) run a Nurse Staffing information day. Different bands of healthcare professionals and other areas of the health board attended this staffing day, and it was extremely interesting to listen to how the All Wales Nurse Staffing Act currently runs in adult acute medical and surgical inpatient divisions.

During the week, I also had some insight into different programmes relating to antimicrobial resistance and healthcare associated infections, which I found very interesting. In meetings with Helen Ronchetti (HCAI Programme Manager) and Paul Gimson (National Primary Care Programme Manager) I learned about the initiatives in community care and within hospitals that aim to reduce the number of healthcare associated infections, and subsequently antimicrobial resistance. Actions including limiting the time that invasive devices such as catheters and cannulas are used for, reducing the over-prescription of medications, including antibiotics, and increasing hydration in the elderly to reduce UTI instances all aim to reduce infections within healthcare. It was interesting to see how these small changes could have a huge impact on healthcare associated infections and antimicrobial resistance.

The Q community has opened its doors to new members again and you may be wondering how this community is dissimilar to the other improvement organisations that are available in health. For me, the Q community IS different. It brings together a unique group of people and has led to learning and opportunities that I just haven’t found elsewhere.

In days gone by one could be forgiven for thinking that improvement or organisational development was the sole job of people who were brought in to fix problems. Now, however, it is very much part of the day job for us all. As a clinician and service lead, I am constantly looking for resources and networks to help me come up with ways of meeting the needs of our population, without having to spend more money, and for me the Q community has been a fantastic opportunity to meet some great people and hear some truly inspirational ideas.

The Q community is run by the Health Foundation. It is a network of people who are interested in improving the health and wellbeing in all its facets. Whilst there are many members who work in the field of continuous improvement or organisational development there are also plenty of professionals from health, care and housing and third sector organisations as well as the people using services themselves.

I joined approximately two years ago and almost immediately got involved in the first of the “Q Labs” which was focused on developing peer support. I have always been a fan of people working with their peers to overcome their challenges. People who are willing to share their lived experience can be so powerful but too often peer support schemes have ended prematurely. The Q Lab enabled me to network with a diverse range of people with a huge amount of combined experience and allowed me to learn some better ways forward. To this end we are now working with Digital Communities Wales to help service users become more confident and proficient at using online resources to support their self management.

I have been impressed by the time and thought that has been put into the design of the Q labs. The materials used in the workshop and the way the process has been put together has been so provoking that I have never left an event with anything other than a head full of ideas and contacts. It has really given me pause for thought with regard to the materials I use in workshops and meetings with service users and colleagues and has shown me what an important part that design plays in improvement. They say good design releases dopamine in the brain and it goes some way to explaining why the process feels so worthwhile.

Recently, I have been participating in the Q Exchange process. At the end of the process is the possibility of receiving up to £30,000 to support a project but equally valuable has been the process of putting together the bid with the support and challenge of other members of the Q community. The input of the community has meant that the project has developed from an initial idea to a much more robust concept that may be worthy of funding. The projects that will be funded will be chosen by the community in September after another round of development. If we are lucky enough to be selected I know that there will be further support to maximise its chance of success.

If you are interested in developing your skills in improving services, want to be exposed to new ideas and challenges, and want to be a part of a kind and supportive community then I highly recommend the Q community to you.